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Vercellini P, Bandini V, Viganò P, Ambruoso D, Cetera GE, Somigliana E. Proposal for targeted, neo-evolutionary-oriented secondary prevention of early-onset endometriosis and adenomyosis. Part II: medical interventions. Hum Reprod 2024; 39:18-34. [PMID: 37951241 DOI: 10.1093/humrep/dead206] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 09/07/2024] [Indexed: 11/13/2023] Open
Abstract
According to consistent epidemiological data, the slope of the incidence curve of endometriosis rises rapidly and sharply around the age of 25 years. The delay in diagnosis is generally reported to be between 5 and 8 years in adult women, but it appears to be over 10 years in adolescents. If this is true, the actual onset of endometriosis in many young women would be chronologically placed in the early postmenarchal years. Ovulation and menstruation are inflammatory events that, when occurring repeatedly for years, may theoretically favour the early development of endometriosis and adenomyosis. Moreover, repeated acute dysmenorrhoea episodes after menarche may not only be an indicator of ensuing endometriosis or adenomyosis, but may also promote the transition from acute to chronic pelvic pain through central sensitization mechanisms, as well as the onset of chronic overlapping pain conditions. Therefore, secondary prevention aimed at reducing suffering, limiting lesion progression, and preserving future reproductive potential should be focused on the age group that could benefit most from the intervention, i.e. severely symptomatic adolescents. Early-onset endometriosis and adenomyosis should be promptly suspected even when physical and ultrasound findings are negative, and long-term ovulatory suppression may be established until conception seeking. As nowadays this could mean using hormonal therapies for several years, drug safety evaluation is crucial. In adolescents without recognized major contraindications to oestrogens, the use of very low-dose combined oral contraceptives is associated with a marginal increase in the individual absolute risk of thromboembolic events. Oral contraceptives containing oestradiol instead of ethinyl oestradiol may further limit such risk. Oral, subcutaneous, and intramuscular progestogens do not increase the thromboembolic risk, but may interfere with attainment of peak bone mass in young women. Levonorgestrel-releasing intra-uterine devices may be a safe alternative for adolescents, as amenorrhoea is frequently induced without suppression of the ovarian activity. With regard to oncological risk, the net effect of long-term oestrogen-progestogen combinations use is a small reduction in overall cancer risk. Whether surgery should be considered the first-line approach in young women with chronic pelvic pain symptoms seems questionable. Especially when large endometriomas or infiltrating lesions are not detected at pelvic imaging, laparoscopy should be reserved to adolescents who refuse hormonal treatments or in whom first-line medications are not effective, not tolerated, or contraindicated. Diagnostic and therapeutic algorithms, including self-reported outcome measures, for young individuals with a clinical suspicion of early-onset endometriosis or adenomyosis are proposed.
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Affiliation(s)
- Paolo Vercellini
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Veronica Bandini
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
| | - Paola Viganò
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Deborah Ambruoso
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
| | - Giulia Emily Cetera
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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2
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Lazzeri L, Andersson KL, Angioni S, Arena A, Arena S, Bartiromo L, Berlanda N, Bonin C, Candiani M, Centini G, Forno SD, Donati A, Exacoustos C, Fuggetta E, Labanca L, Maiorana A, Maneschi F, Mattei A, Muzii L, Ottolina J, Perandini A, Perelli F, Pino I, Porpora MG, Remorgida V, Scaramuzzino S, Schimberni M, Seracchioli R, Solima E, Vignali M, Zupi E, Martire FG. How to Manage Endometriosis in Adolescence: The Endometriosis Treatment Italian Club Approach. J Minim Invasive Gynecol 2023; 30:616-626. [PMID: 37001691 DOI: 10.1016/j.jmig.2023.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 04/03/2023]
Abstract
The evaluation of endometriosis in an adolescent girl is a challenging topic. The initial stage of the disease and the limited diagnostic instrument appropriate for the youth age and for its typical features can reduce the ability of the gynecologist. At the same time, missing a prompt diagnosis can delay the beginning of specific and punctual management of endometriosis, which could avoid a postponed diagnosis from 6 to 12 years, typical of adolescent girls complaining of dysmenorrhea. This article aimed to answer all the potential questions around the diagnosis and management of endometriosis in adolescents starting from a clinical case looking at the possible solution that is easily reproducible in the clinical practice.
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Affiliation(s)
- Lucia Lazzeri
- Department of Molecular and Developmental Medicine (Drs. Lazzeri, Centini, Martire, and Zupi), Università di Siena, Siena, Italy
| | - Karin Louise Andersson
- Department of Territory Health (Dr. Andersson, Exacoustos), Azienda Sanitaria Toscana Centro, Florence, Italy
| | - Stefano Angioni
- Department of Surgical Sciences (Dr. Angioni), Università di Cagliari, Cittadella Universitaria, Cagliari, Italy
| | - Alessandro Arena
- Department of Medical and Surgical Sciences (Drs. A. Arena, Del Forno, and Seracchioli), DIMEC, Sant'Orsola Hospital, Università di Bologna, Bologna, Italy
| | - Saverio Arena
- Department of Obstetrics and Gynecology (Arena), Santa Maria della Misericordia hospital, Perugia, Italy
| | - Ludovica Bartiromo
- Department of Obstetrics and Gynecology (Drs. Bartiromo, Candiani, Ottolina, and Schimberni), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Berlanda
- Department of Obstetrics and Gynecology (Drs. Berlanda and Donati), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Cecilia Bonin
- Azienda Ospedaliera Universitaria Integrata (Drs. Bonin and Perandini), Università di Verona, Piazzale A. Stefani 1, Verona, Italy
| | - Massimo Candiani
- Department of Obstetrics and Gynecology (Drs. Bartiromo, Candiani, Ottolina, and Schimberni), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gabriele Centini
- Department of Molecular and Developmental Medicine (Drs. Lazzeri, Centini, Martire, and Zupi), Università di Siena, Siena, Italy
| | - Simona Del Forno
- Department of Medical and Surgical Sciences (Drs. A. Arena, Del Forno, and Seracchioli), DIMEC, Sant'Orsola Hospital, Università di Bologna, Bologna, Italy
| | - Agnese Donati
- Department of Obstetrics and Gynecology (Drs. Berlanda and Donati), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Caterina Exacoustos
- Department of Territory Health (Dr. Andersson, Exacoustos), Azienda Sanitaria Toscana Centro, Florence, Italy; Department of Surgical Sciences, Gynecologic Unit (Drs. Exacoustos, and Martire), University of Rome "Tor Vergata" Rome, Italy
| | - Eliana Fuggetta
- Department of Obstetrics and Gynecology (Drs. Fuggetta and Maneschi), San Giovanni Addolorata Hospital (Drs. Labanca and Martire), Roma, Italy
| | - Luca Labanca
- Department of Surgical Sciences (Drs. Labanca), Valdarno Hospital, Azienda Toscana Sud Est, Italy
| | - Antonio Maiorana
- Department of Obstetrics and Gynecology (Dr. Maiorana), ARNAS Ospedale Civico Piazza Nicola, Palermo, Italy
| | - Francesco Maneschi
- Department of Obstetrics and Gynecology (Drs. Fuggetta and Maneschi), San Giovanni Addolorata Hospital (Drs. Labanca and Martire), Roma, Italy
| | - Alberto Mattei
- Department of Molecular and Developmental Medicine (Drs. Lazzeri, Centini, Martire, and Zupi), Università di Siena, Siena, Italy; Department of Surgical Sciences, Gynecologic Unit (Drs. Exacoustos, and Martire), University of Rome "Tor Vergata" Rome, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urology (Drs. Muzii, Porpora, and Scaramuzzino), Università di Roma La Sapienza, Policlinico Umberto I, Rome, Italy
| | - Jessica Ottolina
- Department of Obstetrics and Gynecology (Drs. Bartiromo, Candiani, Ottolina, and Schimberni), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessio Perandini
- Azienda Ospedaliera Universitaria Integrata (Drs. Bonin and Perandini), Università di Verona, Piazzale A. Stefani 1, Verona, Italy
| | - Federica Perelli
- Division of Gynecology and Obstetrics (Drs. Mattei and Perelli), Santa Maria Annunziata Hospital, USL Toscana Centro, Florence, Italy
| | - Ida Pino
- Preventive Gynecology Unit (Dr. Pino), European Institute of Oncology IRCCS, Milan, Italy
| | - Maria Grazia Porpora
- Department of Maternal and Child Health and Urology (Drs. Muzii, Porpora, and Scaramuzzino), Università di Roma La Sapienza, Policlinico Umberto I, Rome, Italy
| | - Valentino Remorgida
- Unit of Obstetrics and Gynecology (Dr. Remorgida), University of Eastern Piedmont, Novara, Italy
| | - Sara Scaramuzzino
- Department of Maternal and Child Health and Urology (Drs. Muzii, Porpora, and Scaramuzzino), Università di Roma La Sapienza, Policlinico Umberto I, Rome, Italy
| | - Matteo Schimberni
- Department of Obstetrics and Gynecology (Drs. Bartiromo, Candiani, Ottolina, and Schimberni), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Renato Seracchioli
- Department of Medical and Surgical Sciences (Drs. A. Arena, Del Forno, and Seracchioli), DIMEC, Sant'Orsola Hospital, Università di Bologna, Bologna, Italy; Division of Gynecology and Human Reproduction Phisiopatology (Dr. Seracchioli), IRCCS, Azienda Ospedaliera Universitaria di Bologna, Bologna Italy
| | - Eugenio Solima
- Department of Obstetrics and Gynecology (Drs. Solima and Vignali), Macedonio Melloni Hospital, Milan, Italy
| | - Michele Vignali
- Department of Obstetrics and Gynecology (Drs. Solima and Vignali), Macedonio Melloni Hospital, Milan, Italy
| | - Errico Zupi
- Department of Molecular and Developmental Medicine (Drs. Lazzeri, Centini, Martire, and Zupi), Università di Siena, Siena, Italy.
| | - Francesco Giuseppe Martire
- Division of Gynecology and Obstetrics (Drs. Mattei and Perelli), Santa Maria Annunziata Hospital, USL Toscana Centro, Florence, Italy
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Wüest A, Limacher JM, Dingeldein I, Siegenthaler F, Vaineau C, Wilhelm I, Mueller MD, Imboden S. Pain Levels of Women Diagnosed with Endometriosis: Is There a Difference in Younger Women? J Pediatr Adolesc Gynecol 2023; 36:140-147. [PMID: 36343859 DOI: 10.1016/j.jpag.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
STUDY OBJECTIVE Early diagnosis and treatment of endometriosis affecting adolescent women are important in preventing chronic pain. Our aim was to analyze the clinical characteristics and severity of symptoms in adolescent patients with endometriosis compared with older patients. METHODS This single-center retrospective cohort study in a tertiary referral hospital analyzed women whose first consultation at the certified endometriosis center of Bern University Hospital between January 2017 and December 2020 resulted in the clinical diagnosis of endometriosis. Patients, divided into 2 groups by age, reported visual analog scale (VAS) scores for noncyclic pelvic pain, dysmenorrhea, dyschezia, dysuria, and dyspareunia. The symptom types and severity in the 2 groups were compared. The young patients with endometriosis were analyzed in greater detail, comparing VAS scores and types of endometriosis. RESULTS From a total of 826 patients, 144 (17.4%) patients 24 years old or younger and 682 (82.6%) patients over 24 years old were compared. The younger patients reported significantly higher pain scores for dysmenorrhea (VAS 7.3 vs 6.6; P = .015), dyspareunia (VAS 4.6 vs 3.4; P = .001), and noncyclic pelvic pain (VAS 4.3 vs 3.7; P = .032) compared with the older patient collective. Similar results were found when excluding patients with hormonal treatment. CONCLUSION Young patients with clinically diagnosed endometriosis have significantly higher dysmenorrhea and dyspareunia pain levels than older patients. By acknowledging and understanding this, early diagnosis and adequate treatment can be promoted. Dyspareunia in adolescents in particular merits clinical attention.
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Affiliation(s)
- A Wüest
- Department of Gynecology and Obstetrics, Bern University Hospital and the University of Bern, Bern, Switzerland
| | - J M Limacher
- Department of Gynecology and Obstetrics, Bern University Hospital and the University of Bern, Bern, Switzerland
| | - I Dingeldein
- Department of Gynecology and Obstetrics, Bern University Hospital and the University of Bern, Bern, Switzerland
| | - F Siegenthaler
- Department of Gynecology and Obstetrics, Bern University Hospital and the University of Bern, Bern, Switzerland
| | - C Vaineau
- Department of Gynecology and Obstetrics, Bern University Hospital and the University of Bern, Bern, Switzerland
| | - I Wilhelm
- Department of Anesthesiology and Pain Medicine, Bern University Hospital and the University of Bern, Bern, Switzerland
| | - M D Mueller
- Department of Gynecology and Obstetrics, Bern University Hospital and the University of Bern, Bern, Switzerland
| | - S Imboden
- Department of Gynecology and Obstetrics, Bern University Hospital and the University of Bern, Bern, Switzerland.
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4
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Dixon S, Ranger TA, Burchardt J, Patone M, Snelling AJ, Vincent K, Hippisley-Cox J. Exploring the interface between adolescent dysmenorrhoea and endometriosis: a protocol for a cohort and nested case-control study within the QResearch Database. BMJ Open 2023; 13:e069984. [PMID: 36787972 PMCID: PMC9930556 DOI: 10.1136/bmjopen-2022-069984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
INTRODUCTION Dysmenorrhoea affects up to 70%-91% of adolescents who menstruate, with approximately one-third experiencing severe symptoms with impacts on education, work and leisure. Dysmenorrhoea can occur without identifiable pathology, but can indicate underlying conditions, including congenital genital tract anomalies or endometriosis. There is a need for evidence about the management and incidence of dysmenorrhoea in primary care, the impact of treatments in adolescence on long-term outcomes and when to consider the possibility of endometriosis in adolescence. METHODS AND ANALYSIS This study aims to improve the evidence base for adolescents presenting to primary care with dysmenorrhoea. It comprises three interlinked studies. Using the QResearch Database, the study population includes all female at birth participants aged 10-19 years any time between 1 January 2000 and 30 June 2021. We will undertake (1) a descriptive study documenting the prevalence of coded dysmenorrhoea in primary care, stratified by demographic variables, reported using descriptive statistics; (2) a prospective open cohort study following an index cohort of all adolescents recorded as attending primary care with dysmenorrhoea and a comparator cohort of five times as many who have not, to determine the HR for a diagnosis of endometriosis, adenomyosis, ongoing menstrual pain or subfertility (considered singly and in combination) anytime during the study period; and (3) a nested case-control study for adolescents diagnosed with endometriosis, using conditional logistic regression, to determine the OR for symptom(s) preceding this diagnosis. ETHICS AND DISSEMINATION The project has been independently peer reviewed and received ethics approval from the QResearch Scientific Board (reference OX46 under REC 18/EM/0400).In addition to publication in peer-reviewed academic journals, we will use the combined findings to generate a resource and infographic to support shared decision-making about dysmenorrhoea in community health settings. Additionally, the findings will be used to inform a subsequent qualitative study, exploring adolescents' experiences of menstrual pain.
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Affiliation(s)
- Sharon Dixon
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tom A Ranger
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Judith Burchardt
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Martina Patone
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Andrew Jhl Snelling
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Katy Vincent
- Nuffield Department of Women's and Reproductive Health, Oxford University, Oxford, UK
| | - Julia Hippisley-Cox
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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5
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Angelhoff C, Grundström H. Supporting girls with painful menstruation - A qualitative study with school nurses in Sweden. J Pediatr Nurs 2023; 68:e109-e115. [PMID: 36446692 DOI: 10.1016/j.pedn.2022.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/19/2022] [Accepted: 11/19/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Painful menstruation is common among girls. To optimize school nurses' work more knowledge about their experiences of supporting these girls is needed. The aim of this study was to describe school nurses' experiences of supporting girls with menstrual pain. METHODS Interviews were conducted with 15 school nurses in Sweden and analyzed using thematic analysis. RESULTS Three themes emerged: Taking menstrual pain seriously, Being a disseminator of knowledge, and External conditions for conducting professional work as a school nurse. CONCLUSION School nurses felt competent in supporting girls with menstrual pain. However, they lacked structural, written guidelines and routines for how to treat, support, follow-up and refer girls with menstrual pain. PRACTICE IMPLICATIONS School education about menstruation and sexual health needs to be strengthened. Cooperation with other healthcare facilities and networks with other school nurses should be increased. Specific guidelines on how to support girls with menstrual pain should be implemented.
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Affiliation(s)
- Charlotte Angelhoff
- Crown Princess Victoria's Child and Youth Hospital, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Hanna Grundström
- Department of Obstetrics and Gynecology in Norrköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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6
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Liakopoulou MK, Tsarna E, Eleftheriades A, Arapaki A, Toutoudaki K, Christopoulos P. Medical and Behavioral Aspects of Adolescent Endometriosis: A Review of the Literature. CHILDREN 2022; 9:children9030384. [PMID: 35327756 PMCID: PMC8947708 DOI: 10.3390/children9030384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/19/2022] [Accepted: 03/07/2022] [Indexed: 12/02/2022]
Abstract
The majority of young women will experience discomfort associated with menstrual cycles and miss out on education and social opportunities. Endometriosis, the presence of endometrial glands and stroma outside of uterus, is the most common cause of secondary dysmenorrhea and characterized by pain despite treatment with nonsteroidal anti-inflammatory drugs and hormonal agents. The true prevalence of adolescent endometriosis is not clear. Delay in diagnosis leads to persistent pain, affects quality of life, and potentially contributes to disease progression and subfertility. A laparoscopic diagnosis is the gold standard, but the surgical appearance may differ from adults, as endometriotic lesions are usually red or clear, making their identification a challenge for gynecologists who are unexperienced with endometriosis in adolescents. A personalized medical–surgical treatment is regarded as the most effective therapeutic strategy to achieve remission of symptoms, suppress disease progression, and protect future fertility. Studies have demonstrated how adolescent endometriosis negatively affects patients’ quality of life and psychosocial functioning. Development of therapeutic interventions targeting psychosocial function and quality of life is imperative for adolescent patients.
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7
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Abd Elrahim A, Abdelnaem S, Abuzaid O, Allah MH. Educational Intervention and Referral for Early Detection of Endometriosis among Technical Secondary Schools Students. EGYPTIAN NURSING JOURNAL 2022; 19:141. [DOI: 10.4103/enj.enj_14_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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8
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Wren G, Mercer J. Dismissal, distrust, and dismay: A phenomenological exploration of young women's diagnostic experiences with endometriosis and subsequent support. J Health Psychol 2021; 27:2549-2565. [PMID: 34856840 DOI: 10.1177/13591053211059387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Endometriosis is associated with extensive physical and emotional difficulties, yet there is little research investigating the impact of the diagnostic journey particularly for younger women. Using semi structured on-line interviews and an interpretative phenomenological analysis, this study explored nine young women's experiences of the diagnostic process and the significance of support during this period. Three main themes emerged: 'the pursuit of a diagnosis', 'adjusting to a new normality' and 'the importance of effective support'. These experiences revealed clinical shortcomings and potential improvements to current guidelines and practices to facilitate a more emboldening process for patients.
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9
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Fan X, Duan K, Zhang C, Guan X. Feasibility of two robotic single-site surgery techniques for adolescent endometriosis: Focal versus butterfly. Int J Med Robot 2021; 18:e2339. [PMID: 34661960 DOI: 10.1002/rcs.2339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/24/2021] [Accepted: 10/08/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE This study examined the feasibility of robotic laparoendoscopic single-site surgery (LESS) for the treatment of adolescent endometriosis (n = 36). Additionally, we assessed a novel technique known as butterfly resection for severe cases. METHODS This was a retrospective study of women from 12 to 21 years old who received therapeutic robotic LESS for symptomatic endometriosis by a single experienced surgeon. RESULTS There were 32 cases of peritoneal and four cases of deep infiltrating endometriosis (DIE). Focal resection was performed in 9/32 peritoneal and all DIE cases; butterfly resection was performed in the remaining 23/32 peritoneal. At 3 months, 16/23 had complete resolution of pelvic pain in the butterfly group versus 10/13 in the focal group (P = 0.64). CONCLUSION Robotic LESS produces safe outcomes with low complication rates. Butterfly resection may be considered for extensive lesions, with similar levels of pain relief compared to traditional focal resection techniques. CAPSULE Single-site robotic surgery produces safe outcomes with low complication rates in adolescents with endometriosis, with techniques customized based on disease severity.
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Affiliation(s)
- Xiaodong Fan
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA.,Tianjin Central Hospital of Gynecology Obstetrics Affiliated Hospital of Nankai University, Tianjin, China
| | - Kristina Duan
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Chunhua Zhang
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA.,Department of Obstetrics and Gynecology, Huai'an Maternity and Child Healthcare Hospital Affiliated to Yangzhou Medical University, Jiangshu, China
| | - Xiaoming Guan
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
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10
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Abstract
Early diagnosis and long-term management of endometriosis is important in adolescent girls considering their potential for future pregnancy and need for preventing disease progression. However, symptoms and clinical findings of adolescent endometriosis may differ from those of typical adult endometriosis, making diagnosis difficult. In adolescents, menstrual pain may present as acyclic and unresponsive to commonly used medication. Typical imaging findings in adult endometriosis, such as ovarian endometriotic cysts and fibrotic scars, are less common in adolescents. Peritoneal lesions, characteristic of early-stage endometriosis, are commonly found in this age group. It should be noted that endometriosis may also be found in adolescents before menarche, because of premenarcheal endometriosis or congenital uterine anomaly and outflow obstruction; the latter requiring surgical correction. Although surgery is reported to be effective for pain, postsurgical recurrence rate is high, and the effect of hormonal treatment is controversial. The optimal timing for surgical intervention also remains to be determined. Here, we aim to identify the unique characteristics of endometriosis in adolescents to achieve early diagnosis and optimal management for this group of patients.
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Abstract
Dysmenorrhea is common in adolescents. Most have primary dysmenorrhea and respond to empiric treatment with nonsteroidal anti-inflammatory drugs and/or hormonal therapies. Infrequently, patients have persistent symptoms requiring further evaluation including a pelvic examination, ultrasonography, and/or diagnostic laparoscopy. The most common cause of secondary dysmenorrhea in adolescents is endometriosis. Endometriosis is an estrogen-dependent, inflammatory condition with no surgical or medical cure. Treatment is individualized and typically includes surgical diagnosis with resection and/or ablation limited to visible lesions followed by hormonal suppressive therapy in an attempt to relieve symptoms, limit disease progression, and protect fertility. Multidisciplinary attention to comorbidities and pain management as well as patient education and support are important.
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12
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Findeklee S, Radosa JC, Hamza A, Haj Hamoud B, Iordache I, Sklavounos P, Takacs ZF, Solomayer EF, Radosa M. Treatment algorithm for women with endometriosis in a certified Endometriosis Unit. ACTA ACUST UNITED AC 2020; 72:43-49. [PMID: 32153163 DOI: 10.23736/s0026-4784.20.04490-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Endometriosis is a chronic hormone-dependent disease affecting approximately 25-30% of women in the third and fourth decade. Despite its frequency, it is often detected late. The aim of this overview article was to present a standardized treatment algorithm for an interdisciplinary endometriosis consultation considering conservative and surgical approaches. EVIDENCE ACQUISITION Despite the frequency of endometriosis and a high number of publications dealing with the disease there is a lack of evidence in literature for standardized treatment algorithms allowing a rational diagnostic and therapeutic approach. In May 2019 we did a literature search in Medline. While finding 26702 publications under the term "endometriosis" there was only one publication for the search term "endometriosis consultation treatment algorithm." After screening the abstracts 144 publications in English, French or German language had been assessed as relevant for the diagnosis and therapy of endometriosis (143 overview articles and one guideline). EVIDENCE SYNTHESIS Based on clinical evidence, we have developed a treatment algorithm for women with suspected endometriosis. The diagnosis includes a structured medical history with the identification of endometriosis-typical symptoms and a gynecological examination, if necessary additional examinations. The treatment algorithm is essentially divided into the phase of diagnosis and the phase of therapy as well as the prevention of recurrence or long-term treatment. A multi-professional team of visceral surgery, urology, nutritional medicine, physiotherapy and psychology can be consulted for support. CONCLUSIONS The treatment of endometriosis should be multiprofessional, standardized and reproducible during specialized consultations at certified centers. So far, there are few publications on a standardized and clinically proven treatment algorithm for women with suspected endometriosis. The presented treatment algorithm could be helpful in the diagnosis and treatment of endometriosis patients, even at other centers.
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Affiliation(s)
- Sebastian Findeklee
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, Homburg, Germany -
| | - Julia C Radosa
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, Homburg, Germany
| | - Amr Hamza
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, Homburg, Germany
| | - Bashar Haj Hamoud
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, Homburg, Germany
| | - Iulian Iordache
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, Homburg, Germany
| | - Panagiotis Sklavounos
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, Homburg, Germany
| | - Zoltan F Takacs
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, Homburg, Germany
| | - Erich F Solomayer
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, Homburg, Germany
| | - Marc Radosa
- Department for Gynecology, University Hospital of Leipzig, Leipzig, Germany
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Guo SW. Cancer-associated mutations in endometriosis: shedding light on the pathogenesis and pathophysiology. Hum Reprod Update 2020; 26:423-449. [PMID: 32154564 DOI: 10.1093/humupd/dmz047] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 10/22/2019] [Accepted: 11/19/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Endometriosis is a benign gynaecological disease. Thus, it came as a complete surprise when it was reported recently that the majority of deep endometriosis lesions harbour somatic mutations and a sizeable portion of them contain known cancer-associated mutations (CAMs). Four more studies have since been published, all demonstrating the existence of CAMs in different subtypes of endometriosis. While the field is still evolving, the confirmation of CAMs has raised many questions that were previously overlooked. OBJECTIVE AND RATIONALE A comprehensive overview of CAMs in endometriosis has been produced. In addition, with the recently emerged understanding of the natural history of endometriotic lesions as well as CAMs in normal and apparently healthy tissues, this review attempts to address the following questions: Why has there been such a wild discrepancy in reported mutation frequencies? Why does ectopic endometrium have a higher mutation rate than that of eutopic endometrium? Would the presence of CAMs in endometriotic lesions increase the risk of cancer to the bearers? Why do endometriotic epithelial cells have much higher mutation frequencies than their stromal counterpart? What clinical implications, if any, do the CAMs have for the bearers? Do these CAMs tell us anything about the pathogenesis and/or pathophysiology of endometriosis? SEARCH METHODS The PubMed database was searched, from its inception to September 2019, for all papers in English using the term 'endometriosis and CAM', 'endometriosis and cancer-driver mutation', 'somatic mutations', 'fibrosis', 'fibrosis and epigenetic', 'CAMs and tumorigenesis', 'somatic mutation and normal tissues', 'oestrogen receptor and fibrosis', 'oxidative stress and fibrosis', 'ARID1A mutation', and 'Kirsten rat sarcoma mutation and therapeutics'. All retrieved papers were read and, when relevant, incorporated into the review results. OUTCOMES Seven papers that identified CAMs in endometriosis using various sequencing methods were retrieved, and their results were somewhat different. Yet, it is apparent that those using microdissection techniques and more accurate sequencing methods found more CAMs, echoing recent discoveries that apparently healthy tissues also harbour CAMs as a result of the replicative aging process. Hence endometriotic lesions, irrespective of subtype, if left intact, would generate CAMs as part of replicative aging, oxidative stress and perhaps other factors yet to be identified and, in some rare cases, develop cancer. The published data still are unable to paint a clear picture on pathogenesis of endometriosis. However, since endometriotic epithelial cells have a higher turnover than their stromal counterpart due to cyclic bleeding, and since the endometriotic stromal component can be formed by refresh influx of mesenchymal cells through epithelial-mesenchymal transition, endothelial-mesenchymal transition, mesothelial-mesenchymal transition and other processes as well as recruitment of bone-marrow-derived stem cells and outflow due to smooth muscle metaplasia, endometriotic epithelial cells have much higher mutation frequencies than their stromal counterpart. The epithelial and stromal cellular components develop in a dependent and co-evolving manner. Genes involved in CAMs are likely to be active players in lesional fibrogenesis, and hyperestrogenism and oxidative stress are likely drivers of both CAMs and fibrogenesis. Finally, endometriotic lesions harbouring CAMs would conceivably be more refractory to medical treatment, due, in no small part, to their high fibrotic content and reduced vascularity and cellularity. WIDER IMPLICATIONS The accumulating data on CAMs in endometriosis have shed new light on the pathogenesis and pathophysiology of endometriosis. They also suggest new challenges in management. The distinct yet co-evolving developmental trajectories of endometriotic stroma and epithelium underscore the importance of the lesional microenvironment and ever-changing cellular identity. Mutational profiling of normal endometrium from women of different ages and reproductive history is needed in order to gain a deeper understanding of the pathogenesis. Moreover, one area that has conspicuously received scant attention is the epigenetic landscape of ectopic, eutopic and normal endometrium.
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Affiliation(s)
- Sun-Wei Guo
- Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai 200011, China
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Raźnikiewicz A, Korlacki W, Grabowski A. The role of laparoscopy in paediatric and adolescent gynaecology. Wideochir Inne Tech Maloinwazyjne 2020; 15:424-436. [PMID: 32904632 PMCID: PMC7457195 DOI: 10.5114/wiitm.2020.97817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 06/07/2020] [Indexed: 12/03/2022] Open
Abstract
Paediatric and adolescent gynaecology is a narrow field of medicine dealing with the diagnosis of and treatment of gynaecological diseases from the neonatal period to sexual maturity. The current trend in surgical gynaecology in the paediatric population is to minimise the degree of invasiveness of diagnostic and therapeutic procedures. This contributes to reducing the number of complications and the risk of infertility. Laparoscopic procedures are a challenge for paediatric surgeons and gynaecologists, not only because of the age of treated patients, and anatomical and physiological differences between different age groups but also because of the complexity of the pathology, the differentiation of cancer tumours, and the presence of congenital developmental defects.
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Affiliation(s)
- Aleksandra Raźnikiewicz
- Department of Children's Developmental Defects Surgery and Traumatology, Medical University of Silesia, Katowice, Poland
| | - Wojciech Korlacki
- Department of Children's Developmental Defects Surgery and Traumatology, Medical University of Silesia, Katowice, Poland
| | - Andrzej Grabowski
- Department of Children's Developmental Defects Surgery and Traumatology, Medical University of Silesia, Katowice, Poland
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15
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Sasamoto N, DePari M, Vitonis AF, Laufer MR, Missmer SA, Shafrir AL, Terry KL. Evaluation of CA125 in relation to pain symptoms among adolescents and young adult women with and without surgically-confirmed endometriosis. PLoS One 2020; 15:e0238043. [PMID: 32833998 PMCID: PMC7444809 DOI: 10.1371/journal.pone.0238043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/07/2020] [Indexed: 12/16/2022] Open
Abstract
Endometriosis is a painful gynecologic disease affecting one in ten reproductive aged women worldwide. Few studies have correlated this symptomatology with biomarker levels among women with and without endometriosis, and no studies correlating pain with biomarker levels have been performed in young patient populations. The purpose of this study was to examine whether CA125 correlates with different types and severity of pain among adolescents and young women with and without endometriosis and assess its performance as an endometriosis biomarker among those presenting with dysmenorrhea in this young population. Reproductive-aged women with laparoscopically-confirmed endometriosis (n = 282) and controls (n = 293) who participated in The Women's Health Study: From Adolescence to Adulthood (A2A), a cohort of adolescents and young women enrolled from 2012-2018, were included in this cross-sectional analysis. Plasma CA125 values were measured using WERF EPHect compliant blood samples collected at enrollment. Average CA125 were calculated by self-reported pain type (i.e. dysmenorrhea, non-cyclic/general pelvic pain, dyspareunia), severity, and frequency in endometriosis cases and controls. Median age at blood draw was 24 years in controls and 17 years in cases, with 68% and 89% non-Hispanic white, respectively. Most endometriosis cases (95%) were rASRM stage I/II. Average CA125 values were 12.5 U/mL in controls and 12.1 U/mL in cases adjusted for age. CA125 did not differ by pain type, its severity, or frequency in endometriosis cases or controls. Among participants who reported dysmenorrhea, CA125 did not discriminate endometriosis cases from controls using cutoff of 35 U/mL (AUC = 0.51, 95%CI = 0.50-0.53). Among adolescents and young adult women, CA125 did not correlate with pain type. CA125 did not efficiently discriminate endometriosis cases from controls even when accounting for pain symptomatology. Average CA125 values were low in adolescents and young women in both endometriosis cases and controls, suggesting cautious interpretation may be needed when measuring CA125 in this population.
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Affiliation(s)
- Naoko Sasamoto
- Boston Center for Endometriosis, Boston Children’s Hospital and Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Mary DePari
- Boston Center for Endometriosis, Boston Children’s Hospital and Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Allison F. Vitonis
- Boston Center for Endometriosis, Boston Children’s Hospital and Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Marc R. Laufer
- Boston Center for Endometriosis, Boston Children’s Hospital and Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Gynecology, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Stacey A. Missmer
- Boston Center for Endometriosis, Boston Children’s Hospital and Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, United States of America
- Division of Adolescent and Young Adult Medicine, Department of Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Amy L. Shafrir
- Boston Center for Endometriosis, Boston Children’s Hospital and Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Division of Adolescent and Young Adult Medicine, Department of Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kathryn L. Terry
- Boston Center for Endometriosis, Boston Children’s Hospital and Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Coincidence of uterine malformations and endometriosis: a clinically relevant problem? Arch Gynecol Obstet 2020; 302:1237-1241. [DOI: 10.1007/s00404-020-05750-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022]
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Hung YC, Westfal ML, Chang DC, Kelleher CM. Lack of Data-driven Treatment Guidelines and Wide Variation in Management of Chronic Pelvic Pain in Adolescents and Young Adults. J Pediatr Adolesc Gynecol 2020; 33:349-353.e1. [PMID: 32259629 DOI: 10.1016/j.jpag.2020.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 03/20/2020] [Accepted: 03/27/2020] [Indexed: 01/28/2023]
Abstract
STUDY OBJECTIVE Current literature lacks data-driven guidelines for surgical treatment of adolescent and young adult (AYA) patients with chronic pelvic pain. We hypothesized that there is a significant variation in treatment of these patients, which might be an indicator of over- or undertreatment by some providers. DESIGN AND SETTING We completed a retrospective population-based analysis of the Nationwide Inpatient Sample from 1998 to 2016. PARTICIPANTS We included AYA patients aged 9-25 years whose primary diagnosis was adenomyosis, endometriosis, or chronic pelvic pain. Patients who might have undergone pelvic or abdominal procedures for other primary diagnoses were excluded. INTERVENTIONS AND MAIN OUTCOME MEASURES Trends of inpatient surgical intervention were calculated. Logistic regression was performed to determine the likelihood of undergoing an intervention, adjusted for patient demographic characteristics. RESULTS A total of 13,111 AYA patients were analyzed. Median age at diagnosis was 22 (interquartile range, 20-24) years. The overall inpatient intervention rate was 5879/13111 (45.0%) (2445/5897 (18.6%) for excision/ablation, 2057/5897 (15.7%) for hysterectomy, 1239/5897 (9.5%) for diagnostic laparoscopy, and 156/5897 (1.2%) for biopsy). Rate of hysterectomy increased in the late 2000s while rates of all other interventions decreased. Patients in the northeast were less likely to undergo an intervention than patients in the rest of the country. Rates of intervention also differed according to race, insurance status, and type of hospital. CONCLUSION There is wide variation in the use of surgical treatment for chronic pelvic pain in AYA patients across the country and between types of institutions. Of concern, the rate of hysterectomy has increased over time. There is a need for data-directed treatment guidelines for the management of AYA patients with chronic pelvic pain to ensure appropriate application of surgical treatments and expand high-value surgical care.
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Affiliation(s)
- Ya-Ching Hung
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts; Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Maggie L Westfal
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Cassandra M Kelleher
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts; Department of Pediatric Surgery, MassGeneral Hospital for Children, Boston, Massachusetts.
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Alshehre SM, Duffy S, Jones G, Ledger WL, Metwally M. A prospective, single-centre, single-arm, open label study of the long term use of a gonadotropin releasing hormone agonist (Triptorelin SR, 11.25 mg) in combination with Tibolone add-back therapy in the management of chronic cyclical pelvic pain. Reprod Biol Endocrinol 2020; 18:28. [PMID: 32290838 PMCID: PMC7155249 DOI: 10.1186/s12958-020-00586-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 04/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic cyclic pelvic pain (CCPP) affects women's quality of life and pituitary downregulation is often used for symptomatic relief. However, prolonged suppression of ovarian function is associated with menopausal side effects and can lead to osteoporosis. Currently, the use of gonadotropin releasing hormone agonists (GnRHa) for treatment of CCPP is usually restricted to 6-9 months, limiting their efficacy. There is limited information regarding safety and efficacy with longer-term use. The aim of this study is to examine the safety and efficacy of long-term (24 months) pituitary down-regulation with the GnRHa (Triptorelin SR) with add-back therapy (ABT) using Tibolone for symptom relief in women with CCPP. METHODS A single-arm, prospective clinical trial at a Tertiary University Teaching Hospital of 27 patients receiving Triptorelin SR (11.25 mg) and Tibolone (2.5 mg). Outcomes measures were the safety of treatment assessed by clinical examination, haematological markers, liver and renal function tests and bone mineral density (BMD) at 12, 18 and 24 months as well as at 6 months post-treatment. Pain and health-related quality of life (HR-QoL) assessed using the endometriosis health profile (EHP-30) and chronic pain grade (CPG) questionnaires. RESULTS There was no evidence for any significant harmful effects on any of the measured haematological, renal or liver function tests. Although results regarding the effect on BMD are not conclusive there is an increased risk of development of osteopaenia after 12 months of treatment. Pain and HRQoL assessments showed significant improvement during medication, but with deterioration after treatment cessation. CONCLUSION Long- term Triptorelin plus Tibolone add-back therapy in women suffering from CCPP does not appear to be associated with significant serious adverse events apart from the possibility of deterioration in the BMD that needs to be monitored. This mode of therapy appears to be effective in pain relief and in improving quality of life over a 24-month period. TRIAL REGISTRATION Clinical trials database NCT00735852.
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Affiliation(s)
- Sallwa M Alshehre
- Academic Unit of Reproductive and Developmental Medicine, The University of Sheffield, The Jessop Wing, Tree Root Walk, Sheffield, S10 3HY, Sheffield, UK
| | - Sheila Duffy
- Department of Obstetrics and Gynaecology, The Jessop Wing, Tree Root Walk, Sheffield, S10 3HY, UK
| | - Georgina Jones
- School of Social Sciences, Leeds Beckett University, City Campus, Leeds, LS1 3HE, UK
| | - William L Ledger
- The University of New South Wales, Royal Hospital for Women, Barker Street, Randwick NSW, Sydney, 2031, Australia
| | - Mostafa Metwally
- Academic Unit of Reproductive and Developmental Medicine, The University of Sheffield, The Jessop Wing, Tree Root Walk, Sheffield, S10 3HY, Sheffield, UK.
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Tsonis O, Barmpalia Z, Gkrozou F, Chandraharan E, Pandey S, Siafaka V, Paschopoulos M. Endometriosis in adolescence: Early manifestation of the traditional disease or a unique variant? Eur J Obstet Gynecol Reprod Biol 2020; 247:238-243. [PMID: 32107084 DOI: 10.1016/j.ejogrb.2020.01.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 01/21/2020] [Accepted: 01/29/2020] [Indexed: 10/25/2022]
Abstract
Little is known about Endometriosis in Adolescents and its prevalence is yet to be estimated. Traditional Endometriosis seems to be, by far, quite different with this unique variant when it comes to clinical presentation, management and course of the disease. Further research needs to be conducted in order to classify these two, phenomenically similar, diseases. Adolescents with a history of dysmenorrhea and chronic pelvic pain (CPP) imply findings suggestive of endometriosis. The severity of the disease is variable, from superficial endometriosis to deep endometriotic lesions or even ovarian endometriomas. The course of the disease also suggests the necessity of a more personalized approach since among adolescents, endometriosis could resolve or even aggravate with no particular pathophysiological pattern. Some studies suggest that appropriate treatment should be based on the understanding of the pathophysiologic mechanisms. Long term course of the disease, as well as, a high recurrence rate pose a difficulty to scientists, deciding conservative over operative surgery. Some believe that early operation on superficial forms of endometriosis could potentially prevent deep endometriotic lesions in the long-run. Others find medication such as, combined oral contraceptive pills (COCPs), progestins, levonorgestrel intrauterine device or gonadotrophin releasing hormone analogues (GnRHa), more appropriate for this age group. Last but not least, operation with post-operative hormonal treatment remains the most common treatment approach. Nevertheless, our limited understanding of the disease, as well as, particular factors needed to be taken into consideration, for instance, bone formation in this age group, underline the necessity of further studies, needed to be appointed, in order to determine the best diagnostic and therapeutic approach.
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Affiliation(s)
- O Tsonis
- Specialty Registrar in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University Hospital of Ioannina, Greece.
| | - Z Barmpalia
- Specialty Registrar in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University Hospital of Ioannina, Greece
| | - F Gkrozou
- Consultant in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University Hospital of Birmingham, UK
| | - E Chandraharan
- Consultant in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, St. Georges University Hospital, London, UK
| | - S Pandey
- Consultant in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, St. Georges University Hospital, London, UK
| | - V Siafaka
- Assistant Professor in Health Psychology, Department of Speech and Language Therapy, University of Ioannina, Greece
| | - M Paschopoulos
- Professor in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University Hospital of Ioannina
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Relationship between Patient Age and Disease Features in a Prospective Cohort of 1560 Women Affected by Endometriosis. J Minim Invasive Gynecol 2019; 27:1158-1166. [PMID: 31518709 DOI: 10.1016/j.jmig.2019.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/15/2019] [Accepted: 09/01/2019] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To assess the relationship between age, location of the disease, and surgical procedures performed in patients undergoing surgical management of endometriosis. DESIGN Retrospective study using data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis database. SETTING University tertiary referral center. PATIENTS Women who underwent surgical management of symptomatic endometriosis between April 2009 and April 2014. INTERVENTIONS Patients were allocated to 6 groups according to their age at the time of surgery: ≤20, 21 to 25, 26 to 30, 31 to 35, 36 to 40 and >40 years. Patient characteristics, prior history, location of endometriotic lesions, stage of disease, intraoperative findings, and surgical procedures were retrieved from a prospectively recorded database. MEASUREMENTS AND MAIN RESULTS Patient characteristics, symptoms, location of endometriosis, and type of surgery performed were compared between groups. In total, 1560 procedures were performed. Of these, more than one-half were carried out in women between the age of 26 to 35 years and the majority were performed in women aged between 26 and 30 years. Only 2% of procedures were performed in women under the age of 20 years. The mean stage of the disease at the time of surgical diagnosis was stage II for women younger than 20 years, stage III for those in the age group of 21 to 25 years, and stage IV for those older than 26 years. The rate of diagnosis of deep colorectal nodules increased progressively from 20 to 26 years and remained stable thereafter. CONCLUSION Our data confirm that endometriosis is a disease that probably progresses from adolescence until the adult period when symptoms (pain or infertility) become debilitating and require surgery. Our data suggest that policies relating to the prevention and early diagnosis of endometriosis should focus on women younger than 25 years.
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Alio L, Angioni S, Arena S, Bartiromo L, Bergamini V, Berlanda N, Bonin C, Busacca M, Candiani M, Centini G, D’Alterio MN, Di Cello A, Exacoustos C, Fedele L, Frattaruolo MP, Incandela D, Lazzeri L, Luisi S, Maiorana A, Maneschi F, Martire F, Massarotti C, Mattei A, Muzii L, Ottolina J, Perandini A, Perelli F, Pino I, Porpora MG, Raimondo D, Remorgida V, Seracchioli R, Solima E, Somigliana E, Sorrenti G, Venturella R, Vercellini P, Viganó P, Vignali M, Zullo F, Zupi E. When more is not better: 10 'don'ts' in endometriosis management. An ETIC * position statement. Hum Reprod Open 2019; 2019:hoz009. [PMID: 31206037 PMCID: PMC6560357 DOI: 10.1093/hropen/hoz009] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 12/09/2018] [Indexed: 02/07/2023] Open
Abstract
A network of endometriosis experts from 16 Italian academic departments and teaching hospitals distributed all over the country made a critical appraisal of the available evidence and definition of 10 suggestions regarding measures to be de-implemented. Strong suggestions were made only when high-quality evidence was available. The aim was to select 10 low-value medical interventions, characterized by an unfavorable balance between potential benefits, potential harms, and costs, which should be discouraged in women with endometriosis. The following suggestions were agreed by all experts: do not suggest laparoscopy to detect and treat superficial peritoneal endometriosis in infertile women without pelvic pain symptoms; do not recommend controlled ovarian stimulation and IUI in infertile women with endometriosis at any stage; do not remove small ovarian endometriomas (diameter <4 cm) with the sole objective of improving the likelihood of conception in infertile patients scheduled for IVF; do not remove uncomplicated deep endometriotic lesions in asymptomatic women, and also in symptomatic women not seeking conception when medical treatment is effective and well tolerated; do not systematically request second-level diagnostic investigations in women with known or suspected non-subocclusive colorectal endometriosis or with symptoms responding to medical treatment; do not recommend repeated follow-up serum CA-125 (or other currently available biomarkers) measurements in women successfully using medical treatments for uncomplicated endometriosis in the absence of suspicious ovarian cysts; do not leave women undergoing surgery for ovarian endometriomas and not seeking immediate conception without post-operative long-term treatment with estrogen-progestins or progestins; do not perform laparoscopy in adolescent women (<20 years) with moderate-severe dysmenorrhea and clinically suspected early endometriosis without prior attempting to relieve symptoms with estrogen-progestins or progestins; do not prescribe drugs that cannot be used for prolonged periods of time because of safety or cost issues as first-line medical treatment, unless estrogen-progestins or progestins have been proven ineffective, not tolerated, or contraindicated; do not use robotic-assisted laparoscopic surgery for endometriosis outside research settings. Our proposal is to better address medical and surgical approaches to endometriosis de-implementing low-value interventions, with the aim to prevent unnecessary morbidity, limit psychological distress, and reduce the burden of treatment avoiding medical overuse and allowing a more equitable distribution of healthcare resources.
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Abstract
PURPOSE OF REVIEW The present article provides an overview of the molecular mechanisms underlying adolescent endometriosis and advances in both medical and surgical management. RECENT FINDINGS Molecular and cellular features of endometriotic lesions differ from eutopic endometrium. There is altered estrogen-mediated cell signaling, proinflammatory pathways develop in the local microenvironment, along with impaired cellular immunity and growth factors, cytokines, and angiogenic factors play a critical role. This leads to proliferation and invasion by ectopic endometrial tissue, and natural clearance by the immune system fails. The inflammation, scarring, and adhesions are symptomatically expressed as dysmenorrhea, pelvic pain, and dyspareunia significantly compromising quality of life.In adolescence, there is a significant delay in diagnosis, often because of physician nonresponsiveness. The social, emotional, and physical impact on adolescents is underestimated. Medical management aimed at cessation of menses is paramount, if surgical management is needed, the goal is maximal excision. A variety of new medications, including GnRH and progesterone antagonists, selective estrogen and progesterone receptor modulators, aromatase inhibitors, statins, angiogenic inhibitors, and botanicals represent future treatment options. SUMMARY Early diagnosis of adolescent endometriosis is critical. An understanding of the complex proinflammatory pathways underlying its progression and tailored medical-surgical treatment offers the greatest potential to decrease disease symptomatology.
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Jibrim RLM, de Carvalho CV, Invitti AL, Schor E. Expression of the TFDP1 gene in the endometrium of women with deep infiltrating endometriosis. Gynecol Endocrinol 2019; 35:490-493. [PMID: 30638096 DOI: 10.1080/09513590.2018.1540569] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
The field of endometriosis etiopathogenesis aims to identify the origin of disease in endometrial disorders. Changes in gene and protein expression related to cell adhesion, collagenases, and, mainly, cell cycle regulators have been identified. We set out to analyze the expression of the transcription factor DP-1 (TFDP1) gene, which encodes a protein that controls the G1/S phase passage of the cell cycle, in the endometrium of women with deep infiltrating endometriosis (DIE). Samples of endometrium from both endometriosis-affected women and healthy women were collected, cultured and maintained at the Cell Bank of the Pelvic Pain and Endometriosis Unit of the Federal University of Sao Paulo. This study analyzed five samples from the endometrium cell culture of healthy patients (i.e. no pelvic disease, as determined by means of laparoscopic tubal ligation) and six samples from women diagnosed with DIE. Samples were evaluated for TFDP1 gene expression by real-time PCR. We observed a downregulation of TFDP1 in the endometrium cells of women with DIE when compared to the control (a fold-change of -2.05, p value=.011). The TFDP1 gene is part of the cell cycle pathway, but its function is not yet clear. Additional studies are necessary to clarify the function of TFDP1 in endometriosis etiopathogenesis.
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Affiliation(s)
- Rodrigo Lopes Meime Jibrim
- a Gynecology Department, Pelvic Pain and Endometriosis Unit , Universidade Federal de São Paulo - Escola Paulista de Medicina (UNIFESP-EPM) , Sao Paulo , Brazil
| | - Cristina Valletta de Carvalho
- a Gynecology Department, Pelvic Pain and Endometriosis Unit , Universidade Federal de São Paulo - Escola Paulista de Medicina (UNIFESP-EPM) , Sao Paulo , Brazil
| | - Adriana Luckow Invitti
- a Gynecology Department, Pelvic Pain and Endometriosis Unit , Universidade Federal de São Paulo - Escola Paulista de Medicina (UNIFESP-EPM) , Sao Paulo , Brazil
| | - Eduardo Schor
- a Gynecology Department, Pelvic Pain and Endometriosis Unit , Universidade Federal de São Paulo - Escola Paulista de Medicina (UNIFESP-EPM) , Sao Paulo , Brazil
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Moga MA, Bălan A, Dimienescu OG, Burtea V, Dragomir RM, Anastasiu CV. Circulating miRNAs as Biomarkers for Endometriosis and Endometriosis-Related Ovarian Cancer-An Overview. J Clin Med 2019; 8:jcm8050735. [PMID: 31126056 PMCID: PMC6571871 DOI: 10.3390/jcm8050735] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/13/2019] [Accepted: 05/21/2019] [Indexed: 12/30/2022] Open
Abstract
Early detection and accurate diagnosis are pivotal in the management of endometriosis and endometriosis-related ovarian neoplasms (ERONs), yet there is no clear common ground regarding their pathogenesis. Endometriosis is a debilitating pathology that profoundly impairs the quality of life. Although the spontaneous resolution of endometriosis is possible, studies suggest that it can be a progressive condition, and ERONs can develop. The gold standard for diagnosis remains as the invasive method of laparoscopy followed by histological confirmation. In recent years, novel biomarkers have been discovered. MicroRNAs (miRNA) represent important epigenetic modulators of gene expression and are very attractive as biomarkers due to their lower complexity, tissue specificity, and stability in bodily fluids. Several studies have advanced the possibility of miRNAs becoming potential biomarkers in endometriosis and ERONs. Our aim is to bring these studies together in order to have a better understanding of whether, how, and when miRNAs might be used as biomarkers for these pathologies. METHODS We selected the reviewed papers from Google Academic, PubMed, and CrossRef. A total of eight studies met the inclusion criteria. RESULTS MiR-200 family, miR-143, 145, miR-20a, and miR199a were the most commonly dysregulated miRNAs in endometriosis, and miR-200 family was found to be dysregulated in both ERONs and endometriosis. CONCLUSIONS No single miRNA was considered as a sole biomarker for this pathology. However, since the prognostic value of biomarkers is generally enhanced if more are assessed at the same time, a panel of miRNAs could be a better indicator of the disease.
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Affiliation(s)
- Marius Alexandru Moga
- Department of Medical and Surgical Specialties, Faculty of Medicine, Transilvania University of Brasov, 500019 Brasov, Romania.
| | - Andreea Bălan
- Department of Medical and Surgical Specialties, Faculty of Medicine, Transilvania University of Brasov, 500019 Brasov, Romania.
| | - Oana Gabriela Dimienescu
- Department of Medical and Surgical Specialties, Faculty of Medicine, Transilvania University of Brasov, 500019 Brasov, Romania.
| | - Victoria Burtea
- Department of Medical and Surgical Specialties, Faculty of Medicine, Transilvania University of Brasov, 500019 Brasov, Romania.
| | - Roxana Maria Dragomir
- Department of Medical and Surgical Specialties, Faculty of Medicine, Transilvania University of Brasov, 500019 Brasov, Romania.
| | - Costin Vlad Anastasiu
- Department of Medical and Surgical Specialties, Faculty of Medicine, Transilvania University of Brasov, 500019 Brasov, Romania.
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Burghaus S, Hildebrandt T, Fahlbusch C, Heusinger K, Antoniadis S, Lermann J, Hackl J, Häberle L, Renner SP, Fasching PA, Beckmann MW, Blum S. Standards Used by a Clinical and Scientific Endometriosis Center for the Diagnosis and Therapy of Patients with Endometriosis. Geburtshilfe Frauenheilkd 2019; 79:487-497. [PMID: 31148849 PMCID: PMC6529229 DOI: 10.1055/a-0813-4411] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 10/30/2018] [Accepted: 12/04/2018] [Indexed: 12/22/2022] Open
Abstract
Endometriosis is one of the most common benign gynecological diseases. The extremely heterogeneous complex of symptoms complicates the diagnosis and treatment of this disease. In most patients, there is a latency period of several years between the first occurrence of symptoms and the definitive diagnosis. This paper aims (1) to evaluate standards for the diagnosis and treatment of patients with (symptoms suspicious for) endometriosis in terms of feasibility, and (2) to assess the potential use of data collected by a certified clinical and scientific endometriosis center to answer scientific questions. Standards for outpatient consultations were developed for a special endometriosis outpatient clinic. Between January 2014 and December 2017, a total of 1715 outpatients with a suspicion of endometriosis presented to this special endometriosis outpatient clinic; the diagnosis and treatment of patients was carried out in accordance with the developed standards. Data of this patient cohort obtained from patient records created during outpatient consultations and from a questionnaire recorded in an Oracle-based database was analyzed. The patient cohort was also compared with another patient cohort who had attended different outpatient clinics and had been diagnosed intraoperatively with endometriosis. 41.8% of patients examined during special outpatient consultations had surgery for suspicion or recurrence of endometriosis. Endometriosis was confirmed in 81.5% of cases. Pain symptoms were the main indication for surgery in 70.1% of cases compared to 45.1% of cases in the comparison group. The structured approach used in the special endometriosis outpatient clinic is a key aspect of the care provided by the certified clinical and scientific endometriosis center. It ensures that patients are diagnosed and treated in accordance with guideline recommendations, that diagnosis and treatment comply with certification requirements, and that the collected data can be used to answer scientific questions.
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Affiliation(s)
- Stefanie Burghaus
- Frauenklinik, Universitätsklinikum Erlangen, Universitäts-Endometriosezentrum Franken (UEF), Erlangen, Germany
| | - Thomas Hildebrandt
- Frauenklinik, Universitätsklinikum Erlangen, Universitäts-Endometriosezentrum Franken (UEF), Erlangen, Germany
| | - Christine Fahlbusch
- Frauenklinik, Universitätsklinikum Erlangen, Universitäts-Endometriosezentrum Franken (UEF), Erlangen, Germany
| | - Katharina Heusinger
- Frauenklinik, Universitätsklinikum Erlangen, Universitäts-Endometriosezentrum Franken (UEF), Erlangen, Germany
| | - Sophia Antoniadis
- Frauenklinik, Universitätsklinikum Erlangen, Universitäts-Endometriosezentrum Franken (UEF), Erlangen, Germany
| | - Johannes Lermann
- Klinik für Gynäkologie und Geburtshilfe, Klinikum Bayreuth, Bayreuth, Germany
| | - Janina Hackl
- Frauenklinik, Universitätsklinikum Erlangen, Universitäts-Endometriosezentrum Franken (UEF), Erlangen, Germany
| | - Lothar Häberle
- Abteilung für Biostatistik, Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Stefan P Renner
- Frauenklinik, Klinikum Sindelfingen-Böblingen, Böblingen, Germany
| | - Peter A Fasching
- Frauenklinik, Universitätsklinikum Erlangen, Universitäts-Endometriosezentrum Franken (UEF), Erlangen, Germany
| | - Matthias W Beckmann
- Frauenklinik, Universitätsklinikum Erlangen, Universitäts-Endometriosezentrum Franken (UEF), Erlangen, Germany
| | - Simon Blum
- Frauenklinik, Universitätsklinikum Erlangen, Universitäts-Endometriosezentrum Franken (UEF), Erlangen, Germany
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26
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Ovarian endometriosis and infertility: in vitro fertilization (IVF) or surgery as the first approach? Fertil Steril 2018; 110:1218-1226. [DOI: 10.1016/j.fertnstert.2018.10.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 10/02/2018] [Indexed: 01/01/2023]
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Gupta J, Cardoso LF, Harris CS, Dance AD, Seckin T, Baker N, Ferguson YO. How do adolescent girls and boys perceive symptoms suggestive of endometriosis among their peers? Findings from focus group discussions in New York City. BMJ Open 2018; 8:e020657. [PMID: 29866728 PMCID: PMC5988150 DOI: 10.1136/bmjopen-2017-020657] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Symptoms of endometriosis, including pelvic pain, back and nerve pain, and gastrointestinal pain, often begin in adolescence. Yet, research on the experience of these debilitating symptoms among young people is scarce. Of particular concern is the influence of adolescent girls' social context. This study qualitatively examined how, among adolescents, endometriosis and symptoms suggestive of endometriosis is perceived at the family, peer/school and community/society levels. DESIGN Eight focus groups were conducted; vignettes were used to elicit participants' perceptions of factors that may shape girls' experiences of endometriosis. Data were analysed using constant comparison analysis. PARTICIPANTS An ethnically diverse sample of girls and boys ages 14-18 (n=54) residing in New York City. RESULTS Fifteen themes emerged and were distilled to eight cross-cutting factors that influence perceptions of endometriosis at different levels of the ecological model: distrust of community healthcare providers, societal stigma of menstruation, peer stigma of endometriosis symptoms, distrust of school healthcare providers, lack of endometriosis knowledge among peers and school personnel, inequitable gender norms, invisibility of symptoms and the stigma of teen sex among parents. Further, these factors may compound symptoms' impact on individual girl's social, educational and emotional well-being. CONCLUSIONS Findings underscore the importance of understanding the social environment of girls experiencing symptoms suggestive of endometriosis and educating and engaging their peers, family and school personnel to create a supportive, informed social climate. Efforts should specifically include stigma reduction campaigns targeted towards female and male adolescents.
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Affiliation(s)
- Jhumka Gupta
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, Virginia, USA
| | - Lauren F Cardoso
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Courtney S Harris
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, Virginia, USA
| | - Arielle D Dance
- College of Integrative Medicine and Health Sciences, Saybrook University, Oakland, California, USA
| | - Tamer Seckin
- Endometriosis Foundation of America, New York, USA
| | - Nina Baker
- Endometriosis Foundation of America, New York, USA
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Bordonné C, Merzoug V, Brzakowski M, Tran Ba S, Maitrot-Mantelet L, Chapron C, Dion É. Imagerie du pelvis de l’adolescente. IMAGERIE DE LA FEMME 2018. [DOI: 10.1016/j.femme.2018.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Vercellini P, Facchin F, Buggio L, Barbara G, Berlanda N, Frattaruolo MP, Somigliana E. Management of Endometriosis: Toward Value-Based, Cost-Effective, Affordable Care. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:726-749.e10. [DOI: 10.1016/j.jogc.2017.07.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 07/12/2017] [Indexed: 12/13/2022]
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30
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Koninckx PR, Ussia A, Keckstein J, Adamyan LV, Zupi E, Wattiez A, Gomel V. Evidence-Based Medicine: Pandora's Box of Medical and Surgical Treatment of Endometriosis. J Minim Invasive Gynecol 2018; 25:360-365. [DOI: 10.1016/j.jmig.2017.11.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 11/18/2017] [Indexed: 02/06/2023]
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